Luminal structure anchoring devices and methods

ABSTRACT

The present invention relates to a device for endoscopy or endosonography-guided transluminal interventions whereby two luminal structures in the body may be drawn toward each other and a fluid conduit formed in between. The device may have a hollow central member to which is coupled a distal retention member and in one embodiment a proximal retention member. The retention members may each be positioned inside one of the luminal structures and expanded from a first condition to an expanded second condition having an increased radius. The length of the central member may be shortened and its diameter expanded to approximate the two retention members and thereby the luminal structures.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.11/867,636 filed on Oct. 4, 2007, entitled “Luminal Structure AnchoringDevices and Methods”, and issued as U.S. Pat. No. 8,425,539 on Apr. 23,2013, which is a continuation-in-part (CIP) of U.S. application Ser. No.10/822,138, filed Apr. 12, 2004, entitled “Automated TransluminalTargeting Device and Anchoring Devices and Methods”, the disclosures ofwhich are hereby expressly incorporated by reference.

FIELD

The invention relates to a device for endoscopy or endosonography-guidedtransluminal interventions whereby an anastomosis can be formed betweentwo luminal structures in the body. More specifically devices andmethods are described to anchor, create a fluid conduit and toapproximate luminal structures using an expandable hollow stent.

BACKGROUND

Endoscopy and endosonography-guided interventions have certainadvantages over alternative surgical and percutaneous-guided procedures.Interventions that employ endoscopy or endosonography may avoid some ofthe harmful effects of alternative procedures. One technique that hasbeen explained is a technique for endoscopy and endosonography-guidedbiopsy. Such a technique and associated devices are described, forexample, in U.S. Pat. No. 6,228,039, which is hereby expresslyincorporated by reference. A need exists, however, for other diagnosticand therapeutic interventional applications and related devices that maybe performed in an endoscopy or endosonography-guided environment.

In particular, a need exists for such devices and techniques that cantraverse a first layer of tissue, such as the wall of the bowel,bladder, or other organ or structure that can be accessedendoscopically, and penetrate into or through another layer of tissuesuch as the wall of a hollow or solid organ, hollow body, luminalstructure, duct, vessel, or soft tissue structure, such as a muscle orligament. In certain surgical operations, for example, a need exists tobe able to connect and create an artificial lumen (anastomosis) betweentwo neighboring luminal structures, such as, for example, two segmentsof bowel. Sometimes the need exists to approximate the two luminalstructures before or simultaneous to the creation of an artificial lumenor connecting conduit.

Further, a need exists in certain surgical procedures to attach or affixtwo neighboring structures, such as the stomach to the diaphragm(gastroplexy) or the bladder to the abdominal wall (cystoplexy).Additionally, a need exists to be able to connect a first portion of thestomach with a second portion of the stomach (stomach stapling). A needalso exists to be able to affix diagnostic and therapeutic devices to anorgan or tissue. For example, a need exists to be able to implant agastric pacemaker to treat gastroparesis. Furthermore, a need exists toperform the functions described above in a manner that is automated. Forexample, in circumstances in which it is desired that an operation takeplace from within a luminal structure, a surgeon may have limitedability to manipulate a needle, anchor, or other penetrating device toperform procedures such as those listed above, and in particular toposition tissue or to create an artificial lumen. Thus, a need existsfor an appropriate automatic tissue targeting device.

Furthermore the need exists to connect, approximate and create anartificial lumen (anastomosis) between two neighboring luminalstructures. Such an artificial lumen preferably has a large diameter. Alarge diameter artificial lumen or conduit may facilitate fluid exchangebetween the luminal structures, the insertion of instruments or theremoval of body tissues such as gall stones from one structure toanother.

SUMMARY OF THE DISCLOSURE

The present invention may solve the needs in the art stated above andmay provide certain advantages over the prior art. The present inventionsolves the need for the ability to perform additional techniques byproviding an apparatus capable of use in such techniques.

One embodiment of the present invention may be an apparatus including aroughly hollow cylindrical central member having a proximal end and adistal end; a leg member, attached to a distal end of the centralmember, wherein at least a portion of the leg member is adapted topermit production of an expanded distal radius in the apparatus; atether attached to a proximal portion of the central member; an expandermember, a distal portion of which is aligned co-axially through thecentral member; and a pusher member aligned co-axially around a proximalportion of the expander member and adapted to prevent the movement in aproximal direction of the central member.

In an embodiment employing a cylindrical central member, there may be anumber of leg members. These leg members may, for example, be segmentsof the cylinder. In an embodiment shown in FIG. 4, for example, the legmembers are shown curled back, but it may be apparent from that figurethat the four legs are each roughly a quarter of the circumference ofthe cylinder. Of course, there is no requirement that the legs beimplemented in such a manner or comprise such a circumference of thecylinder. For example, a cylindrical member may be used. Such acylindrical member may be adapted to transform from an approximatelycylindrical shape to an approximately conical or pyramidal shape. Someexamples include a “leg” deployed like the canopy of an umbrella, or a“leg” deployed by removing a sheath from an elastic (when reference ismade to elastic, reference to superelastic is included) member shapedsomewhat like a shuttlecock. Additionally, a multiplicity of legs, suchas 2, 3, 4, or more legs may be used. Such legs may be malleable orelastic. An example material for use as an elastic material is a shapememory alloy such as Nitinol. Other structures that may be used as a leginclude, for example, tines, fingers, or hooks. The deployment of legsmay be described as an expanding process, or by other teens, such as anunfurling process.

In an embodiment that may be employed in the lumen of a tissue or organ,the distal end may refer to the end most outwardly radial. In general,the distal end refers to the end closest to the first layer of tissueprior to normal use.

Another embodiment of the present invention may be the apparatusdescribed above, but further including a pre-biasing device adapted toselectively force at least a portion of the apparatus in a distaldirection, and an outer sleeve surrounding the apparatus, wherein theouter sleeve is adapted to be fitted to an endoscope. The outer sleevemay be attached to the described apparatus directly or medially, or maybe slidably positioned relative to the apparatus. The outer sleeve mayaid the operator in directing the application of the apparatus to targettissue.

Another embodiment of the present invention may be an apparatusincluding a roughly hollow cylindrical central member having a proximalend and a distal end; a leg member, attached to a distal end of thecentral member, wherein at least a portion of the leg member is adaptedto permit production of an expanded distal radius in the apparatus; asuture attached to a proximal portion of the central member; an expandermember, a distal portion of which is aligned co-axially through thecentral member; a pusher member aligned co-axially around a proximalportion of the expander member and adapted to prevent the movement in aproximal direction of the central member; and a tether connected to aproximal portion of the expander member.

Another embodiment of the present invention may be an apparatusincluding a roughly hollow cylindrical central member having a proximalend and a distal end; a leg member, attached to a distal end of thecentral member, wherein at least a portion of the leg member is adaptedto permit production of an expanded distal radius in the apparatus; anda shoulder member attached to a proximal end of the central member, theshoulder member being adapted to limit movement of the central member ina distal direction. The shoulder member may be collapsible to allowdeployment and may be configured to automatically and/or manuallydeploy.

Another embodiment of the present invention may be an apparatusincluding a roughly hollow cylindrical central member having a proximalend and a distal end, and a leg member, attached to a distal end of thecentral member, wherein at least a portion of the leg member is adaptedto permit production of an expanded distal radius in the apparatus.

Another embodiment of the present invention may be an apparatusincluding a roughly hollow cylindrical central member having a proximalend and a distal end; a leg member, attached to a distal end of thecentral member, wherein at least a portion of the leg member is adaptedto permit production of an expanded distal radius in the apparatus; anda tether attached to a proximal portion of the central member.

Another embodiment of the present invention may be methods of use,including anchoring a second tissue to a first luminal structure,wherein the second tissue is anchored by use of an expandable anchorthat is adapted to perform the steps of penetrating through a firstluminal structure, penetrating at least into a portion of a secondtissue, and holding the second tissue in approximately constant positionrelative to at least a region of the first luminal structure. The stepof holding the second tissue in approximately constant position relativeto at least a region of the first luminal structure may be performed byan embodiment of the present invention including an anchor, withoutregard to the speed or precise manner by which the anchor is inserted.

In such a method of use, the second tissue may be a luminal structure.Moreover, these luminal structures may be a hollow organ such as asegment of the bowel (for example, esophagus, stomach, small intestine,and colon), bladder, gallbladder, uterus, or bronchotracheal tree. Theseluminal structures may also be ductal structures such as the bile duct,pancreatic duct, urethra, or ureter. These luminal structures may alsobe vascular structures such as an artery or a vein. The cylindricalcentral members described above may serve to create a conduit oranastomosis between two luminal structures.

One embodiment of the present invention may be an apparatus including asubstantially hollow central member adapted to permit the passage of apenetrating member adapted to penetrate tissue and a first leg memberconnected to a distal portion of the central member, wherein the firstleg member may be adapted to produce an increase in a distal radius ofthe apparatus and wherein the increase may be adapted to restrain motionof the apparatus in a proximal direction. An embodiment may, forexample, be adapted such that the first leg member employs a techniquefor producing an increased radius such as by being self-expanding or bybeing manually expandable. In a particular embodiment, the first legmember may be adapted to expand in radius in response to the proximalmotion of the penetrating member.

An embodiment may, for example, be fashioned with the first leg memberincluding a shape memory alloy. Other parts of the embodiment may alsoinclude shape memory alloy, such as, for example, the hollow centralmember.

In a particular embodiment, the first leg member may include a first endconnected to a distal portion, and a second end that extendsapproximately proximally prior to increasing the radius of theapparatus. The first leg member may, for example, include a first endconnected to a distal portion, and may also include a second end thatextends approximately distally prior to increasing the radius of theapparatus.

In an embodiment of the present invention, the first leg member may beadapted to expand in radius in response to the proximal motion of anencompassing sheath. Such a sheath may be particularly valuable in anembodiment in which shape memory or a self-expanding mechanism is usedto increase a distal, medial, or proximal radius of the device.

In a further embodiment of the present invention, the apparatus may alsoinclude a second leg member connected to a proximal portion of thecentral member, wherein the second leg member is adapted to produce anincrease in the proximal radius of the apparatus and wherein theincrease is adapted to restrain motion of the apparatus in a distaldirection. Such an embodiment may be designed such that the second legmember is adapted to expand in radius in response to the proximal motionof an encompassing sheath. In a particular embodiment, the second legmember may be adapted to expand in radius by means of one or more rubberbands.

In a particular embodiment, the hollow central member may be adapted tobe a stent, the stent having an inner lumen. This stent may be coveredto facilitate the passage of fluid through the inner lumen of the stent.Furthermore, the central member may be adapted to be expandable indiameter so that exchange of fluids is enhanced or the introduction ofvarious instruments is facilitated. Additionally, the central member mayinclude a shape memory alloy mesh. Such a mesh may be an expandable meshthat is trained to an expanded diameter but restrained to a narrowerdiameter by a removable encompassing sheath.

A further embodiment of the present invention may also include a tabconnected to the central member and directed radially inward. The tabmay be adapted to translate force in an axial proximal direction intoforce in a radially outward direction.

A further embodiment of the present invention may include a method offorming a conduit between a distal and a proximal luminal structureincluding positioning a distal retention member in or near the distalluminal structure and positioning a proximal retention member in or nearthe proximal luminal structure. The distal and proximal retentionmembers are coupled to a hollow central member. The method further mayinclude drawing the distal and proximal retention members toward eachother such that a portion of the luminal structures are brought intocloser approximation than before the intervention and held in closeapproximation to each other. The method may further include expandingthe distal retention member and/or expanding the proximal retentionmember so that these retention members may act as anchors to secure theluminal structures to the retention members.

A further embodiment of the present invention may include shortening thecentral member as part of the approximation method described. This maybe facilitated by the application of an axial compression force on thecentral member such that the length of the central member is shortenedand the diameter of the central member is expanded. The central membermay also be a stent or mesh that is comprised of two concentric hollowsections that shorten by sliding one hollow section inside the other.

In one particular embodiment of the present invention the device may beremovable from the body once the therapeutic need has been met.Furthermore the device may be reabsorbed by the body or in other wordsthe device may be bioabsorbable.

It is understood that both the foregoing general description and thefollowing detailed description are exemplary and explanatory only andare not restrictive of the invention as claimed. The accompanyingdrawings illustrating an embodiment of the invention and together withthe description serve to explain the principles of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a drawing of an installation device for the anchors and otherhardware of the present invention.

FIG. 2 is a detail drawing of a relevant portion of FIG. 1.

FIG. 3 is a sectional view of an embodiment of the present invention.

FIG. 4 is a perspective view drawing of an embodiment of the presentinvention that may be an anchor and may be, as shown, in an expandedstate with leg members deployed.

FIG. 5 is another perspective view drawing of an embodiment of thepresent invention that may be an anchor and may be, as shown, in anunexpanded state

FIG. 6 is a four step side view partial cutaway drawing of an embodimentof the present invention in use.

FIG. 7 is another four step side view partial cutaway drawing of anembodiment of the present invention in use.

FIG. 8 is a drawing of an embodiment of the present invention includingan anchor with an expander and a sensor or treatment delivery deviceattached to a tether.

FIG. 9 is a drawing of an embodiment of the present invention includingtwo anchors (with expanders) connected by two tethers.

FIG. 10 is a drawing of an anchor with a shoulder.

FIG. 11 is a cross-section drawing of an anchor with a shoulder that mayserve as a stent.

FIG. 12 is a drawing of an anchor with a separate shoulder.

FIG. 13 is a drawing of an anchor with a separate shoulder installed onthe anchor.

FIG. 14 is a drawing of an alternative embodiment of the presentinvention including a release device.

FIG. 15 is a drawing of an embodiment of the present invention includingan anchor without an expander and further including a suture with a loopat the proximal end, with the loop optionally attached to a sensor ortreatment delivery device.

FIG. 16 is a drawing of an embodiment of the present invention includingtwo anchors (without expanders) connected by two sutures.

FIGS. 17A and 17B are drawings of an embodiment of an anchor with acollapsible shoulder.

FIG. 18 is a two-step sectional view drawing of an embodiment of thecollapsible shoulder anchor in use.

FIG. 19 is a four-step sectional view of an embodiment of the inventionwith an anchor that may serve as an expandable stent.

FIG. 20 is a perspective view drawing of an embodiment of the presentinvention with an anchor with a separate expandable shoulder.

FIG. 21 is a sectional view drawing of an anchor (with an expandableshoulder) situated in a portion of bowel and securing another luminaltissue structure to the bowel.

FIGS. 22A-H are detailed depictions of detailed views of an expandablestent in combination with an anchor.

FIG. 23 is a four-step sectional view of an embodiment of the inventionwith an anchor that may be used to approximate luminal structures andserve as an expandable stent.

FIG. 24 is a sectional view showing an anchor with an expandable centralmember having a covering.

FIG. 25 is a four-step sectional view of an embodiment of the inventionwith a restraining member covering a self expanding stent.

FIG. 26 is a four-step sectional view of an embodiment of the inventionshowing an inflatable balloon to expand a stent anchor.

FIG. 27 is a perspective view of an anchor that can be shortened inlength by sliding two members together.

FIG. 28 is a five-step perspective view of an embodiment of theinvention including a method to remove an anchor.

FIG. 29 is a perspective view of a collapsible valve member.

DETAILED DESCRIPTION

It is to be understood that the present invention is not limited to theparticular methodology, compounds, materials, manufacturing techniques,uses, and applications, described herein, as these may vary. It is alsoto be understood that the terminology used herein is used for thepurpose of describing particular embodiments only, and is not intendedto limit the scope of the present invention. It must be noted that asused herein and in the appended claims, the singular forms “a,” “an,”and “the” include the plural reference unless the context clearlydictates otherwise. Thus, for example, a reference to “a suture” is areference to one or more sutures and includes equivalents thereof knownto those skilled in the art. The materials that may be used inconjunction with the present invention may include conventionalmaterials such as stainless steel, other surgical alloys of steel,various biocompatible plastics and elastomers, and other conventionalmaterials. In general it may be valuable to avoid using materials thatare likely to cause allergic reactions or inflammation, unless such aresult is desired.

Reference herein to the term “endoscope” refers not only to conventionalendoscopes, but also to any rigid, semi-rigid, or flexible opticalinstrument for use in visual examinations of the interior of the humanbody. Such examinations may include, for example, examinations of bodilycanals or vessels such as blood vessels or hollow organs such asstomachs, intestines, colons, the heart or bladders. The term“endoscope” also includes angioscopes and also echo-endoscopes, whichmay include an ultrasound transducer at, for example, the tip of thedevice.

The present invention may be an embodiment that permits the automationof a tissue penetrating device by means of a pre-biasing device, whichincludes a member such as compressed gas compartment, a coil spring, ora torsion spring. In a specific embodiment, an integrated spring coilcomponent, such as a compression spring component, may be used. Althougha compression spring coil may be one component that may be used toforward-bias a portion of the device, other components may be used aswell. For example, other types of elastically deformed mechanical springelements, compressed air, chemical combustion, or magnetic repulsion (orattraction) may also be used a pre-biasing device.

The compression spring, or other pre-biasing device, may be loaded. Onrelease of the component, a tissue-penetrating component may shootforward at high velocity. The velocity that may be desirable may dependon the tissue whose penetration is desired. A high velocity operationavoids striction effect and hence is more repeatable and accurate. Thus,the device may be able to penetrate in a more predictable and preciselycalculable fashion. Further, the device may penetrate more than onetissue in a single forward movement or in more than one forwardmovement.

Thus, the device may be used to penetrate through the wall of a luminalstructure into and through a wall of an adjacent luminal structure.Thereafter, the adjacent tissue may be engaged by an anchoring orconnecting member. Thus, the device may be able to create an anastomoticconnection between two luminal structures.

In certain embodiments, a device according to the present invention maybe a tissue penetrating device that is inserted though theinstrumentation channel of an endoscope, echo-endoscope, or the like.The handle of the device may be attached to the inlet port of theendoscope or echo-endoscope. Examples of such endoscopes are found, forexample, in U.S. Pat. Nos. 6,638,213; 6,614,595; and 6,520,908. Thetissue penetrating device may be manually advanced or retracted.Additionally, the forward-biasing device (for example, a compressionspring) may be loaded and released. This may enable the tissuepenetrating device to shoot forward with high velocity on the release ofthe device, which may occur via the release (or depression) of atrigger.

The tissue penetrating device may, for example, take the form of abarbed needle. The needle may be housed in a protective outer sheath.The outer sheath may serve to protect the instrumentation channel in theendoscope from the needle, as well as to protect the needle. The outersheath may be adapted to be separate from the tissue penetrating device.Thus, the outer sheath may be moved independently of the tissuepenetrating device. The outer sheath may further serve as a guide forthe tissue penetrating device. Finally, the outer sheath may also serveto dilate or enlarge a tissue penetration tract. The handle of thedevice may be screwed and thereby securely anchored into the inlet portof the instrumentation channel of the endoscope using a Luer lockmechanism. This may be useful to prevent the handle from back-firingafter the forward-biasing device is activated.

In the example of a spring-loaded embodiment, the distance of forward(or as it will be referred to herein, distal) movement of the tissuepenetrating device may be controlled at the handle. For example, in oneembodiment, the degree to which the spring is compressed or the degreeto which the spring is permitted to travel may precisely control thedistal movement of the tissue penetrating device. In an embodiment inwhich an anchor is to be inserted, the method of insertion is notessential to the operation of the anchor, although controlled, rapidinsertion may accrue the benefits described.

FIG. 1 depicts an installation device for the anchors and other hardwareof the present invention, and may be an embodiment of the presentinvention. FIG. 2 is a detailed depiction of a portion 2 of FIG. 1. Thisinstallation device may, for example, be attached to an endoscope orechoendoscope. An example of such an attachment may be found in U.S.Pat. No. 6,228,039, which is hereby incorporated in its entirety hereinby reference.

The embodiment depicted in FIGS. 1 and 2 may be assembled as follows.The activation cable assembly (including outer sheath 40, pusher 50,tether 60, and suture 20) may be threaded. The locknut 330 may beinstalled prior to threading. The locknut 330 may be used to assemblethis embodiment together with an endoscope.

Next the suture 20 may be pushed through an opening that may be providedin main cylinder 200 and outer sleeve 210. Next, outer sleeve 210 may beattached to an endoscope via locknut 330 or via other appropriateattachment device. The outer sheath 40 may be attached onto the maincylinder 200 using an appropriate connection, such as a screw (notshown). Main cylinder 200 may be fastened to outer sleeve 210 by stopscrew 220. The stop screw 220 may permit setting the relative positionof main cylinder 200 and outer sleeve 210. One position that may beuseful is one in which outer sheath 40 is consequently adjusted to anappropriate place within a patient. Sliding piston 230 may be tensionedand locked using pre-bias latch/release (not shown) as described in U.S.Pat. No. 6,228,039. It may be valuable to identify whether pusher 50 isin correct axial position along outer sheath 40. If not, it may bevaluable to adjust the position of pusher 50 accordingly. Stop screw 260may be used to lock pusher 50 in an appropriate position once adjusted.Calibration cap 250 may be turned on mating threads on main cylinder 200to adjust the amount of travel upon the release of the compressionspring 240. End cap 270 may be installed into the end of pusher 50. Theend cap 270 may be pushed down until the end of its axial travel hasbeen reached. The end cap 270 may then be fastened in place with alocking screw 280. This step of installation may be performed withoutclamp nut 290 or expansion nut 300 in place.

Clamp nut 290 together with anti-rotation pin 320 and expansion nut 300may be installed over the tether 60. In this embodiment, expansion nut300 may snap over clamp nut 290 to form a subassembly. Expansion nut 300may be screwed down the threads of end cap 270 until the shoulderscontact. It may be valuable to confirm that tether 60 is appropriatelyplaced. The locking screw 310 may then be tightened.

The device as described to this point may be used to deploy the anchor(not shown). After deploying the anchor, the expansion nut 300 may berotated backwards until the proper expansion of the anchor (not shown)has been obtained. Expansion nut 300 may be connected to tether 60.Tether 60 may be connected to an expander. Turning expansion nut 300creates relative motion between tether 60 and pusher 50.

FIG. 3 depicts an embodiment of the present invention in a sectionalview. This embodiment of the present invention may be inserted intotissue. This embodiment includes an expander 30 at a distal end of theapparatus, three anchors 10, a pusher 50, an outer sheath 40, sutures20, and a tether 60. In this example, the expander 30 may be forcedthrough a surface in a distal direction. The other elements depicted,except for the outer sheath, may also at least partially penetrate thesurface. Thus, for example, one of the anchors 10 may partiallypenetrate the surface. A mechanism (not shown) may be used to retractthe expander 30 in a proximal direction. The pusher 50 may prevent theanchor 10 from retracting in the proximal direction. As the expander 30retracts, it may force the anchor 10 to expand. This expansion mayresult in anchor 10 having a greater diameter at its distal end. Thusthe anchor 10 may be prevented from moving back through the surface in aproximal direction. However, a tether 60 may provide a tensile force inthe proximal direction that may keep the anchor in contact with thepenetrated surface. In certain circumstances, it may be advisable toapply an anchor 10 that has a suture 20 attached. Additionally, althoughthis method may use motion of the expander, it may also use motion ofthe anchor relative to the expander.

FIG. 4 depicts an embodiment of the present invention that may be ananchor. This embodiment includes an expanded-form anchor 10 at a distalend and a suture 20 at a proximal end. As shown here, an anchor 10 maybe expanded (shown already expanded), creating a distal region with aneffective diameter larger than the hole occupied by the more proximalregion. A suture 20 may be attached to the expanded anchor 10. Thesuture 20 may, in some embodiments be more easily attached prior toexpansion of the anchor 10. In particular, it may be desirable to attachthe suture before penetrating a surface with the anchor.

FIG. 5 depicts another embodiment of the present invention that may bean anchor. This embodiment includes an anchor 10 at a distal end and asuture 20 at a proximal end. As shown, the anchor 10 may be in apre-expansion form. Such a form may be useful, for example, in aiding inthe insertion of an anchor through a surface. As shown here, a suture 20may be attached to the anchor 10 prior to expansion.

FIG. 6 depicts the use of an embodiment of the present invention in foursteps. In the first step (at top), the apparatus as a whole is shown ashaving been partially inserted through a first layer of tissue 80 (whichmay, for example be the bowel wall), and into a second layer of tissue70 (which may, for example, be connective tissue outside the bowelwall). In the next three steps (proceeding downward), the expander 30may be gradually retracted. This gradual retraction may force anchor 10in its unexpanded state to partially expand. Eventually, the legs ofanchor 10 may be fully expanded. In this instance, the anchor 10 may beretracted until it engages an outer surface of the first layer of tissue80. A suture 20 may remain attached and extend through the first layerof tissue 80. The expander 30 and pusher 50 may be eventually completelywithdrawn. In this instance the tether 60 may remain attached to theexpander 30.

An alternative means of expanding the anchor 10 may be accomplished asfollows. The anchor 10 may be constructed with legs made from a shapemetal alloy, such as a nickel-titanium alloy. The legs may be pre-biasedto assume an expanded state. However, the legs of the anchors may bemaintained in an unexpanded state by means of a restraining sheath.Gradual retraction of the sheath may allow the legs to expand to theirpre-biased expanded state. This mechanism may thus make use of thesuper-elastic properties of the shape-memory alloy. Alternatively, atemperature change memory effect of an alloy may also be used, by (forexample) training the alloy into an expanded state, bending the legsinto an unexpanded state, and then raising the temperature of the alloyabove the necessary threshold to return it to the memorized expandedstate. The temperature change may be accomplished by a variety of meanssuch as the use of a heating element.

FIG. 7 depicts another use of an embodiment of the present invention infour steps. In the first step (at top), the apparatus as a whole isshown as having been partially inserted through a first layer of tissue80 (which may be, for example, the bowel wall), and into a second layerof tissue 70 (which may be, for example, a structure made of muscletissue such as the diaphragm, and may, as shown here, be adjacent to thefirst layer of tissue 80). In the next three steps (proceedingdownward), the pusher 50 may advance anchor 110 against expander 30.This advancement may force anchor 110 in its unexpanded state topartially expand. Eventually, the anchor 110 may be fully expanded. Asshown, the anchor 110 may be left completely within the second layer oftissue 70. In this embodiment, the tether 60 and the expander 30 mayremain partially within the second layer of tissue 70. For example, theexpander 3 may lie completely with the second layer of tissue 70, andthe tether 60 may remain attached and extend from the second layer oftissue 70, through the first layer of tissue 80. The pusher 50 may bewithdrawn in a proximal direction. As previously discussed, theexpansion may take place by any relative opposing motion of the expanderand anchor. Additionally, an anchor may be deployed by prebiasing a legto an expanded radius, constraining or constricting the leg to anarrower radius, and then removing the restraint. Such a technique mayinclude the use of a superelastic leg constrained by a sheath. As thesheath is removed in, for example, a proximal direction, the leg mayexpand the distal radius of the anchor.

FIG. 8 depicts an embodiment of the present invention including a sensoror treatment delivery device 120. In this embodiment, the anchor 110 maylie within a second layer of tissue 70. A tether 100, may pass through afirst layer of tissue 80, and connect the anchor 110 with a sensor ortreatment delivery device 120. Examples of sensors 120 include cameras,electromagnetic sensors, manometry sensors, pH probes, and probes forlumen content sampling. Example of treatment delivery devices 120include pharmaceutical delivery devices; chemotherapy delivery devices;treatment activation devices (e.g. photodynamic therapy devices);radioisotope containment or delivery devices; thermal or radiofrequencydelivery devices; radioisotope containers; thermal, photochemical, andradio frequency delivery devices; and stimulating electrode devices,including pacemakers and nerve stimulators. Attachment of the sensor ortreatment delivery device 120 to tether 100 may be accomplished by, forexample, a nail, screw, bolt, clip, knot, loop, friction mount, oradhesive mechanism. A tether may be a suture, but it may also be a morerigid material, and may be an inflexible material. Examples of materialsthat may serve as a tether include a wire.

FIG. 9 depicts an embodiment of the present invention including twoanchors 110 connected by two tethers 100. In this example, the anchorsand tethers may be inserted as previously described. However, thetethers 100 may further be connected by a lock ring 140. Drawing thetethers together may allow the margins of the first layer of tissue 80and the second layer of tissue 70 to approximate and close a tear or gapin tissue continuity 130.

FIG. 10 depicts an anchor 10 with a shoulder 150. In this embodiment ofthe present invention, an anchor 10 (shown expanded) may be providedwith a shoulder 150. This shoulder 150 may be adapted to prevent overpenetration by providing significant resistance to further penetration.FIG. 11 depicts an anchor 10 with a shoulder 150 passing through a firstlayer of tissue 80 and a second layer of tissue 70. In this example, theanchor 10 may be provided with a hollow center. Thus, when in place, asshown, the anchor 10 may serve as a stent. The stent may, for example,be self expanding or mechanically expandable. A balloon may be used toexpand the stent, and this may permit the stent to acquire an increaseddiameter as shown in FIG. 26. Tabs may be provided directed radiallyinwardly to convert some of the force of an expander moving in an axialdirection into a radially expansive force on the stent.

FIG. 12 depicts an anchor 160 with a separate shoulder 170. In thisembodiment, the anchor 160 and the shoulder 170 are in two pieces. Thesepieces may be adapted to engage one another. This may be accomplished,for example, by providing the pieces with corresponding threads, byarranging for a light frictional fit, or by tensioning tethers 180 whileadvancing rod 190. One advantage of this design may be the ease ofremoval. In particular, the shoulder 170 may be restrained from movingin a proximal direction, and tension may be applied in a proximaldirection to the anchor 160. This may force the anchor 160 through theshoulder 170 in a proximal direction, collapsing the anchor 160 in theprocess.

FIG. 13 depicts an anchor 160 with a separate shoulder 170 as installed.This anchor 160 is otherwise the same as FIG. 10. It is an object of theinvention to provide a device that efficiently and effectivelypenetrates tissue in a precisely targeted manner for a diagnostic ortherapeutic endoscopy or endosonography-guided transluminal procedures.

The present invention may be a puncturing or penetrating member thatincludes or is provided with a tissue anchoring or engaging member. Thepuncturing member may be integral with the tissue anchoring member. Forexample, a barbed needle would integrate both a tissue penetrating andtissue anchoring member. In another embodiment the members may beseparate. For example, an anchor may be provided that may be fittedaround a tissue penetrating member. The tissue penetrating member mayalso be adapted to be withdrawn in such a manner that it expands thedistal radius of the anchor member. The anchoring member may involvesuch devices as crossbars, flanges, hooks, barbs, adhesive, or clips.The anchoring member may also be a gas or liquid inflatable element,such as a balloon. The puncturing member may be detachable by means ofan elongate link such as a thread, wire, strand, or cord.

Referring to FIG. 14, such an embodiment of the present invention mayinclude a tissue penetrating device, an outer sleeve 210, and a handle1410. The handle 1410 may include a main cylinder 200 that houses asliding piston 230, and a compression spring 240. The upper (proximal)end of the outer piston may have a shoulder above which the compressionspring 240 may be loaded. In a particular embodiment, when the outerpiston, is maximally advanced in the main cylinder 200, the compressionspring 240 may be relaxed (as opposed to tightly compressed) andhandgrip may be in contact with the calibrating sleeve. The outer pistonmay be retracted by pulling back on the handgrip, thereby loading thecompression spring 240 by compressing it.

The main cylinder may be provided with a trigger that has a spring.Retraction of the outer piston may engage this spring in the groove,thereby locking the outer piston in the locked position. Pressing abutton may release this lock, allowing the compression spring to uncoil(relax) and advance the outer piston distally at high velocity.

The handgrip may be provided with a screw that secures the position ofthe inner piston 230 that contains the tissue penetrating device. Thecalibrating sleeve may be adjusted proximally to shorten the distancethat the outer piston will progress after the spring is released. Thus,the distance of the tissue penetrating device may be preciselycalibrated. An outer sleeve 210 may be connected and secured to the maincylinder 200 with a screw. The outer sleeve 210 may be screwed into theinstrumentation channel inlet port of the endoscope or echo-endoscope byscrew attachment. The outer sheath 40 may screw into the main cylinder.By loosening the screws, the position of the outer sleeve 210 may beadjusted relative to the main cylinder 200. Such an adjustment mayadjust the exposed length of the outer sheath 40.

FIG. 15 depicts an embodiment of the invention similar to that shown inFIG. 8. In this embodiment, the expander has been removed from theanchor 110. The suture 105 may be attached to the anchor 110 in anon-coaxial position. The suture may have a loop or other member at theproximal end which may be used to attach a sensor or treatment deliverydevice. It may be advantageous to remove the expander from the anchor110 because the expander may be used to expand anchors at otherlocations. Attachable devices may include, for example, treatmentactivation devices (e.g. photodynamic therapy devices), radioisotopecontainment devices, radioisotope delivery devices, thermal deliverydevices, or radio frequency delivery devices. Although the invention isdescribed in terms of an expander, the expander may also be used fornon-expansion purposes (such as to aid in penetrating tissue) and may(in some instance) not be used for any expansion purpose. For example,if a leg (or a plurality of legs) of shape memory alloy is used, thedeployment mechanism may be the withdrawal or rupture of an encompassingsheath.

FIG. 16 depicts an embodiment of the invention similar to that shown inFIG. 9. In this embodiment, the expanders have been removed from theanchors 110. The suture 106 may be attached to the anchor 110 in anon-coaxial position. It may be advantageous to remove the expander fromthe anchor 110 because the expander may be used to expand anchors atother locations. Sutures 106 may be connected by a lock ring 140.

FIGS. 17A and 17B depict an anchor 1030 with a collapsible shoulder1040. Anchor assembly 1010 shows the distal legs of an anchor deployedwith a collapsible shoulder mechanism at the proximal end of the anchorin its pre-deployed position. Shoulder tabs 1040 pivot on the anchor1030 and may be connected to the anchor 1030 with elastic tensionmembers 1050 such as silicone rubber bands. An encompassing sheath (notshown) may prevent the shoulder tabs 1040 from deploying until it theencompassing sheath 1065 retracted. Once the sheath 1065 is retracted,the shoulder tabs 1040 on anchor assembly 1020 may be forced by theelastic tension members 1050 to deploy and form a shoulder that mayprevent the distal motion of the anchor 1030. The distal legs (if morethan one leg is used) may be implemented by a superelastic alloy. Insuch a configuration, the distal legs may be trained to produce anexpanded distal radius, and may be constrained by the encompassingsheath 1065 to a narrower radius. Such an arrangement may require fewerdiscrete components.

FIG. 18 depicts the use of the collapsible shoulder mechanism in twosteps. In the first step (at top), the anchor 1030 is shown penetratinga first layer of tissue 1070 and a second layer of tissue 1080 with itslegs already deployed. An encompassing sheath 1065 is shown in positionrestraining the opening of shoulder tabs 1040 against the applied forcefrom the elastic tension member 1050. The next step depicts theretraction of the expander 1055 and its associated tether 1060 and theencompassing sheath 1065. These components may be retractedsimultaneously or sequentially. The encompassing sheath 1065 may beremoved first so that the expander 1055 and tether 1060 may stabilizethe anchor 1030 prior to deployment of the collapsible shoulder. Theencompassing sheath 1065 may be removed and the shoulder tabs 1040 maybe forced into place against the second layer of tissue 1080 by theforce supplied by elastic tension members 1050. As described elsewhere,the encompassing sheath 1065 may also deploy legs by releasing aconstraint on the legs. Additionally, the encompassing sheath 1065 maybe releasably attached to a distal portion of the legs. The distalportion of the leg may be slightly spooned inward, so that its distalportion extends slightly radially outwardly. As the sheath is retracted,the ends of the legs may be pulled in a proximal direction. This maycause the legs to form an approximately U-shaped configuration which mayhave the effect of expanding a distal radius of the device. At asuitable time, the encompassing sheath may release the legs after theyhave formed such a shape. For such a deployment, as with deployment byan expander, it may be advantageous to use a leg formed of a malleablematerial.

FIG. 19 depicts the use of an expandable stent in combination with ananchor. The figure shows a series of four steps of installing an anchorwith an expandable stent. In the first step (at top), the combinationanchor with expandable stent 1110 may be inserted through two layers oftissue 1170 and 1180. An expander 1130 may be located coaxially withinthe anchor 1110. The expander 1130 may be retracted proximally by, forexample, a tether (not shown). A pusher 1150 may be slipped over theexpander 1130 and positioned coaxially with the expander 1130. Thepusher 1150 may be used to counteract axial loads or forces applied bythe expander 1130 to the anchor 1110 in a proximal direction. In thesecond step, the expander 1130 may cause the distal legs of the anchorto deploy. Simultaneously, the pusher 1150 may cause the proximal legsof the anchor to expand. The expander 1130 and pusher 1150 may then makecontact with tabs in the anchor. This contact may prevent their furtheraxial motion. Application of increased tensile force on the tether (notshown) connected to the expander 1130 and increased compression force onthe pusher 1150 may load the anchor 1110 in compression.

The compression loading of the anchor 1110 may yield the material andcause plastic deformation. The anchor body may be formed of an openmesh-like structure that expands in diameter as it yields and is forcedinto a shorter axial configuration. The third step in the figureillustrates an intermediate point of expansion of the diameter. Finally,the fourth step depicts the anchor fully expanded and the expander 1130and pusher 1150 retracted from the anchor 1110. It would also bepossible to expand the stent portion of the anchor with an inflatableballoon. The expandable stent depicted in FIG. 19 could also beconfigured with a collapsible shoulder mechanism as illustrated in FIGS.17 and 18. Such a stent may be made of a malleable material. Similarly,a stent may be made of a superelastic alloy. Such a stent may beconstrained to a first diameter by an encompassing sheath (not shown)and may resume a larger diameter after the sheath is removed.

FIGS. 22A-H depicts detailed views of an expandable stent 2200 incombination with an anchor. Referring to FIGS. 22A and 22E (FIG. 22E isthe sectional view A-A of FIG. 22A), the anchor may be delivered to thesite with the legs 160 straight and the stent 2200 may initially be inan unexpanded state. Referring to FIGS. 22B and 22F (FIG. 22F is thesectional view B-B of FIG. 22B), the legs 160 may be deployed by meansof the action of an expander device (not shown) moving coaxially throughthe anchor (from distal end towards proximal end). Referring to FIGS.22C and 22G (FIG. 22G is the sectional view C-C of FIG. 22C), the stent2200 diameter may be expanded. The expander that deployed the legs mayalso be used to expand the stent as well. Tabs 2210 may be formed on thestent 2200. Such tabs 2210 may be bent radially inward. Such a bend maycatch the expander as it is pulled toward the proximal end of theanchor. Continued pulling on the expander may cause the stent 2200 toplastically deform. The mesh-like walls of the stent 2200 may cause thestent diameter to increase as the stent length is reduced by thecompressive force applied through the expander. A pusher device, notshown, may counteract the force applied by the expander and may therebykeep the anchor stationary. The stent 2200 may approximately double indiameter (compare FIGS. 22A and 22D). In another configuration thediameter may increase more than double. The reduction in length withincreased diameter is also illustrated in FIGS. 22D and 22H (FIG. 22H isthe sectional view D-D of FIG. 22D). Also compare FIGS. 22E and 22H. Thecoaxial expander may be used (if desired) to perform a part of theexpansion (or none at all). Other ways to effectuate the expansion ofthe stent 2200 include using a shape-memory alloy such as Nitinol thatmay be pre-biased to the expanded state. The unexpanded stent 2200 maybe constrained in a sheath that may be retracted once in the stent is inthe proper position. Another way to expand the stent 2200 is to deformthe stent 2200 into a larger diameter using an inflatable balloon.

FIG. 20 depicts an anchor 1260 with a separate expandable shoulder 1270.In this embodiment, the anchor 1260 and the shoulder 1270 are twoseparate pieces. The pieces may be adapted to engage each other. Thismay be accomplished as described above for the configuration shown inFIG. 12. Tethers 1280 and 1290 may be provided for applying tension tothe anchor 1260 and compression to the expandable shoulder 1270. Theexpandable shoulder 1270 may have its legs deployed in the same fashionas described earlier for deploying the legs of an anchor. An expander(not shown) may be forced between the legs of the expandable shoulder1270 in a distal direction, and this forced movement may expand thelegs. FIG. 21 depicts the embodiment of the invention shown in FIG. 20installed between the stomach 1380 and section of bowel 1370 to createan anastomosis.

Automatic operation of the penetrating device and pre-biasing thepenetrating device may occur via use of, for example, a mechanicalspring. Other pre-biasing devices may include, for example, compressedair or chemical explosion. In the example of a spring biasing device, assoon as the spring is released, the penetrating device may thrustsforward into a layer of tissue. By virtue of the greater inertia of themass of the endoscope (if one is used in conjunction with the presentinvention), the penetrating device may experience all (or almost all) ofthe relative motion and may pass through even hardened tissue. The highvelocity of the penetrating device may lessen the bending of thepenetrating device and may help to overcome the striction effects. Morespecifically, according to the device of the present invention, thepenetrating device pre-biased may rush forward after a release (orlaunch) device provided with the pre-biasing device is operated.Further, the use of the penetrating device of the invention may resultin avoiding the potentially undesirable (in certain circumstances)repeated reciprocating motion that may be required by conventionaltechniques and devices. In this case, the penetrating device that may belocated in the passage formed in the endoscope may be surrounded by aprotecting sleeve. The sleeve may be made of an impenetrable materialthat may be moved independently of the penetrating device. The movablesleeve may protect and may reinforce the penetrating device and mayposition the penetrating device appropriately, even after thepenetrating device has moved out of the passage provided in theendoscope.

In order to reliably move the penetrating device forward and to preventthe pre-biasing device from projecting, the housing of the pre-biasingdevice may be set into screw engagement with the opening of the passageprovided in the endoscope. Adjusting means (such as, for example, screwsor slides) may precisely adjust the position of the penetrating deviceand the forward movement of the pre-biasing device.

Referring to FIG. 14, the penetrating device may include an operatingand pre-biasing device. The device may have a main cylinder 200 in whicha sliding piston 230 may be provided. The sliding piston 230 may have aprojection 1420 on its top end. To the projection 1420 there may beattached a spring 240 for pre-biasing the penetrating device. A releasedevice 1430 having a spring 1440 may be provided on the main cylinder200. The spring 1440 may be set into a groove 1450 made in the slidepiston, when the penetrating device or the slide piston 230 is biased.At the end of the slide piston 230, which may be distant from thepenetrating device, a grip 300 may be provided to move the piston 230,thereby performing automatic penetration. On the grip 300 a stop pin 280may be provided, by which the penetrating device may be secured. As longas the spring 240 is released, the grip 300 may remain in contact with acalibration cap 250. The position of the calibration cap 250 may bechanged to adjust the end position of the piston 230 and hence thepenetration depth of the penetrating device.

An outer sleeve 210 may be provided on the end of the main cylinder 200,which may be near the penetrating device. This end of the cylinder 200may hold the pre-biasing and control device in the penetrating devicepassage provided in the endoscope. The main cylinder 200 may be fastenedto the outer sleeve 210 by means of a stop pin or screw 220. The outersleeve 210 may be fixed in the open end (inlet port) of the penetratingdevice passage of the echo-endoscope by means of a screw attachment1460. Standard endoscopes and “interventional” echo-endoscopes can beused. Using an interventional echo-endoscope, the angle of departure ofthe penetrating device may be adjusted at the echo-endoscope. Thetransducer at the end of the echo-endoscope may be surrounded by a latexballoon. The latex balloon can be filled with water during the use ofthe echo-endoscope. The water can serve as a medium between thedetection probe and, for example, the intestinal wall.

The penetrating device may extend through an outer sheath that may bemade, for example, of a flexible metal weave or impenetrable plastic.The penetrating device may be inserted into the endoscope by theoperating- and pre-biasing device until it projects, along with thesleeve, from the lower end of the endoscope. In certain cases, it may bedesired that the penetrating device tip be beveled and that the distalend of the penetrating device be sand-blasted, pitted, or otherwisealtered to improve the resolution of ultrasonic imaging.

A dull stylet may be located in a hollow penetrating device (in somesituations in which a hollow penetrating device is desired) and may beflush with or may project by approximately 2 mm from the open end of thepenetrating device. The proximal end of the penetrating device, whichmay be ready for insertion into the operating and pre-biasing device,may be set in screw engagement with the proximal end part of theoperating and pre-biasing device.

In the device according to the invention, the penetrating device can bemanually moved back and forth by loosening the stop pin provided on thegrip. The position of the penetrating device can therefore be manuallyadjusted. Referring to FIG. 14, the slide piston 230 may be drawn backgreatly. If so, the groove 1450 may move toward the spring 1440,compressing the coil spring 240. When the spring 1440 comes intoengagement with the groove 1450, the penetrating device may bepre-biased and can be quickly moved forward by the release device 1430.The calibrating sleeve 250 may adjust the depth of penetration of thepenetrating device. A coarse adjustment may be possible in accordancewith the depth of insertion of the main cylinder 200. At this stage inthe use of the device, the main cylinder 200 may be fixed in place bystop pin or screw 220. A quick and accurate adjustment of thepenetrating device may be performed by manipulation of the outer sleeve210 provided at the end of the main cylinder 200. Once the stop pin orscrew 220 is loosened, while the stop pin 280 at the grip remainstightened, the protective sheath attached to the main cylinder 200 andthe penetrating device secured to the slide piston may be insertedtogether into the outer sleeve 210 until they become visible by theendoscope. Thereafter, the stop pin or screw 220 may be tightened,whereby the calibrating sleeve 250 may adjust the depth of penetrationwith precision. The stylet (if one is used, a stylet is not required forthe present invention) may be drawn a little from the hollow penetratingdevice, releasing the sharp end of the hollow penetrating device. Thesharp end of the penetrating device first penetrates a first layer oftissue, such as the intestinal wall, and then comes close to a secondlayer of tissue that is to be punctured.

As soon as the penetrating device reaches the tissue to be punctured,the stylet may be removed and may be replaced by any device or substancethat may be set into contact with the other end of the hollowpenetrating device. The stop pin 280 provided on the grip 300 may beloosened to insert the penetrating device into the tissue to bepunctured. To accomplish manual puncture, the stop pin 280 may beloosened and the penetrating device may be moved back and forth withrespect to the main cylinder 200. When the manual puncture is difficultto achieve or when the tissue is hard to penetrate, the release device1430 may release the elastic spring 240. Thus, the penetrating devicemay project forward into the hardened tissue.

Regarding one goal of this invention, the automation of the installationof anchors, one skilled in the art should recognize that it is possibleto further automate the installation of anchors. As shown in FIG. 3, forexample, it is possible to have multiple anchors staged near the distalend of the apparatus. The installation device may, thus, be readilymodified to provide a cocking action that compresses the spring,retracts the pusher member through the next anchor and advances a nextanchor and pusher member toward the expander.

As shown in FIG. 23, the device according to an alternate embodiment ofthe invention may be used to approximate two luminal structures to forma conduit in between. The device depicts the use of a central member4108 that has a distal anchor 4110, or sometimes referred to as a distalretention member, coupled at the distal end of the central member. Thecentral member 4108 also may have a proximal anchor 4112, or sometimesreferred to as a proximal retention member, coupled at the proximal endof the central member. The figure shows a series of four steps ofinstalling these anchors with a central member. The central member 4108may be an expandable member that is capable of shortening in length asit expands in diameter. Examples of such expandable members may bedeformable stents, self-expanding stents, expandable meshes, or Nitinolshape memory material that expands in response to a heat source eitherbody temperature or through applied resistance heat. The central member4108 may be a conduit that is adapted to transfer fluid from one end ofthe central member to the other. In the first step (at top), theexpandable central member 4108 with coupled anchor 4110 may be insertedthrough two layers of tissue 4170 and 4180 that are part of first andsecond luminal structures. These luminal structures may be separated bya space S. One example of these types of luminal structures may be thestomach and the gall bladder which may be positioned next two oneanother or be separated by a distance inside the abdominal cavity. Anexpander 4130 may be located coaxially within the central member 4108and the anchors 4110 and 4112. The expander 4130 may be retractedproximally by, for example, a tether (not shown). A pusher 4150 may beslipped over the expander 4130 and positioned coaxially with theexpander 4130. The pusher 4150 may be used to counteract axial loads orforces applied by the expander 4130 to the anchor 4110 in a proximaldirection. In the second step, the expander 4130 may cause the legs ofthe distal anchor to deploy. When the expander 4130 is retractedproximally, the substantially straight legs of the distal anchor curlradially outwardly causing an increase in the diameter of the anchor.The legs may partially curl or may fully curl. When the legs are fullycurled, a substantially round ring like shape is formed as shown insteps 2 and 3. This fully curled condition may be useful to present ananchor interface with the tissue that reduces trauma to the tissue. Inthe case of partial curling, the legs may be used to actually penetratethe tissue layers 4170 and 4180. This partially curled position may beuseful to secure the anchor to the tissue layer. Simultaneously, thepusher 4150 may cause the legs of the proximal anchor to expand. Whenthe pusher 4150 is advanced distally, the substantially straight legs ofthe proximal anchor curl radially outwardly causing an increase in thediameter of the anchor. The legs may partially curl or may fully curl.The expander 4130 and pusher 4150 may then be used to apply a furtheraxial compression force through the tabs in the anchor.

In one embodiment of the invention this axially applied compressionforce may be used to draw the two luminal structures closer togetherthereby reducing the space S between the luminal structures byshortening the effective longitudinal length of the central member. Thisis illustrated in the second and third steps. This approximation ofluminal structures may be useful to reduce the distance betweenstructures to facilitate fluid exchange between the two or to improvethe accessibility of these structures by positioning therapeuticinstruments into one from the other. In step four, the walls of thestructures are shown side by side each other but this amount ofapproximation may not be necessarily required.

Continued application of increased tensile force on the tether (notshown) connected to the expander 4130 and increased compression force onthe pusher 4150 may load the central member 4108 in compression whichmay also cause further deformation of the central member resulting in anenlargement of the central member diameter. This increase in diametermay be useful to increase fluid exchange between the two luminalstructures or to allow larger sized instruments such as scopes into thesecond luminal structure. Although the process of decreasing the centralmember length to approximate the luminal structures and increasing thediameter to increase fluid flow and accessibility may occur separately,these processes may also occur sequentially or even simultaneouslydepending on the design of the central member.

The central member may have a thin covering or membrane 4160 disposedabout it that is designed to seal the central member to provide a fluidconduit that inhibits fluid leaks between the fluids of the luminalstructures and the fluids of the abdominal cavity or other anatomicalspaces. This is depicted in FIG. 24. It is preferred that when thecentral member and the anchors are fully deployed that a stable fluidconduit is established so that fluids may pass from one luminalstructure to another without significant loss of fluid. The covering4160 may be an elastic covering that can expand or contract as thecentral member expands and contracts. If the central member is anexpandable stent, the covering should be designed to seal the gapsbetween the braids of the stent thereby sealing the outside of the stentand making the stent internal diameter capable of conduction fluids.Although in Figures

As shown in FIG. 25, the expandable central member 4108 may be a selfexpanding stent or mesh that is constrained in a small diameterconfiguration and then self expands as a restraining member is removed.The self expanding member is shown restrained by an encompassing sheath4170. As the encompassing sheath 4170 is withdrawn the expandablecentral member 4108 enlarges to an expanded condition with a diameterthat is larger than the restrained configuration. Such expansion may beaccompanied with a concomitant shortening of the member length along thelongitudinal axis.

As shown in FIG. 26, the expandable central member 4108 may be anexpanding stent or mesh that must be expanded by the use of a dilatingballoon 4172. The dilating balloon 4172 may be positioned inside thestent and with the balloon in a deflated condition. Once inside thestent or mesh the balloon 4172 may be inflated to expand the diameter ofthe member as shown in the third and fourth steps. Once the member issufficiently expanded, the balloon may be deflated and withdrawn leavingbehind a central expanding member with an expanded inside diameter.

Alternately the expandable central member 4108 may be an expanding stentor mesh that is constructed from a metal alloy material such as Nitinolthat expands from a first diameter to an expanded diameter by theexposure to body heat or by applying a current to the mesh or stent suchthat raises the temperature of the metal alloy so that a programmedshape may form. An alternative embodiment of the invention isillustrated in FIG. 27. This device is similar to that previouslydescribed in FIG. 20. This device illustrates two separate anchors 1260and 1270 which are both coupled to central members 1271 and 1272respectively. The central members 1271 and 1272 are coaxially alignedsuch that central member 1271 is slidably positioned inside centralmember 1272. This device is designed to allow for variable functionaldistances between anchors 1260 and 1270. After the anchors 1260 and 1270are positioned in or about the first and second luminal structuresrespectively and the anchors are expanded as shown in FIG. 27, the twoluminal structures may be approximated by drawing the two anchors 1260and 1270 close to each other. As the anchors and thereby the luminalstructures are approximated, the central member 1271 slides insidecentral member 1272 and the distance between the anchors 1260 and 1270decreases. The central members may be provided with a ratchetingmechanism (not shown) that permits selective anchor to anchor separationdistances. In this embodiment the approximation of the luminalstructures may controlled by the operator. This may be preferablebecause the amount of approximation possible for one situation with oneset of luminal structures may be different from another situation. Thisembodiment may allow the operator to decide the optimal luminalstructure spacing in situ and reduce the amount of further interventionsrequired. Once the optimal spacing is determined, the two centralmembers may lock in position together by utilizing various lockingapparatus well known to those skilled in the art. Such lockingmechanisms may include bayonet locks, compression locks such as bytwisting one central member relative to the other, tab and slot or othermechanisms. If a device such as this is removed, the two central membersmay be unlocked from each other and the smaller central member 1271removed from the first luminal structure. The second central member 1272may be subsequently removed by collapsing the anchor 1270 and removingthe device from the second and the first luminal structures.

As described above, it may be necessary to remove a device that has beenpositioned across two luminal structures. In one method a grasper may beintroduced to the proximal end of the central member or to the proximalanchor coupled there. The grasper may grasp the proximal anchor and pullproximally. This axial force may pull the central member proximally andthe distal anchor coupled to it. Sustained axial displacement of thegrasper may cause the distal anchor to uncurl as the central member iswithdrawn. The grasper may finally remove the device from the tissuelayers.

Another embodiment of the present invention is illustrated in FIG. 28that is designed to permit removal of a device once deployed. As shownin the first illustration of FIG. 28, the device is deployed from afirst luminal structure across wall 4180 and across wall 4170 and into asecond luminal structure. This deployment is similar to that previouslydescribed in FIG. 23. The device has been deployed such that the twowalls 4170 and 4180 have been approximated, anchors 4110 and 4111 havebeen expanded and are deployed at or into the walls as shown and thecentral member 4108 is in an expanded condition. The expanded device maybe removed by the introduction of a removal device having a distal probe4115 which has a foldable barb 4113 positioned on at least one side ofthe probe sidewall near the distal tip of the probe. The foldable barbis collapsed flush with the outside wall of the probe for introductionand can be made to unfold to at least a 30.degree. angle. A proximalprobe 4118 is concentrically positioned about the distal probe 4115 andhas at least two hooks 4116 coupled to the distal end of the proximalprobe 4118. These hooks are configured to attach to the proximal end ofthe device near the proximal anchor 4111.

As shown in the second step of FIG. 28, the removal device is positionedinside the expanded central member and the proximal probe is attached tothe proximal end of the central member near the proximal anchor 4111. Inthe case where the central member is a stent, the hooks 4116 of theproximal probe may for example ensnare the braids of the stent. Thedistal probe is brought near the distal opening of the expanded centralmember and the foldable barbs are deployed such that they impinge on theinside walls of the central member. If the central member is an expandedstent, the barbs are designed to wedge against the sidewall of thestent. In this configuration the removal device is ready to beginremoval of the expanded central member 4108. The distal probe 4115 isadvanced distally as shown by the arrow in the second step illustration.Simultaneously the proximal probe 4118 is withdrawn proximally in thedirection of the arrow shown in the second step illustration. Thisaction applies a tensile force on the expanded central member anddeforms and stretches the expanded central member so that the length ofthe central member increases and the diameter subsequently decreases.This may move the central member away from the walls of the luminalstructures as the central member lengthens and the diameter decreases.It is understood that minimal stretching of the central member may berequired to facilitate its removal and the walls 4170 and 4180 maycollapse around the central member as it is stretched. The centralmember should be stretched sufficiently so that the anchors 4110 and4111 may be extricated from their respective walls 4170 and 4160. Oncethe anchors are separated from the walls, which may be visible usingdirect endoscopic visualization or using ultrasound or other diagnosticmethods, the proximal anchor 4111 is removed or detached from theproximal end of the central member 4108. A collapsing sleeve 4120 isthen slid over the distal probe 4115 and advanced over the probe 4115until the distal anchor 4110 contacts the collapsing sleeve 4120. Theposition of the distal probe 4115 may be maintained as the collapsingsleeve is advanced distally by applying a tensile force to a tether 4122attached to the proximal end of the distal probe. As the collapsingsleeve is further advanced the legs of the distal anchor 4110 arestraightened and contained within the collapsing sleeve 4120. Finallythe collapsing sleeve 4120, distal anchor 4110 and the central member4108 may be removed together.

Alternatively the device may be constructed with materials that areknown to be bioabsorbable such that after a certain period of time, thedevice including the anchors and the central member may be reabsorbed bythe body. This type of device may have several distinct advantages. Thistype of device does not require subsequent interventions to remove itafter a period of time. This is less invasive and potentially safer andmore comfortable foe the patient. Secondly as the device begins to breakdown slowly, it is probable that the first and second luminal structureswill repair the opening in their walls naturally as the device degradesso that a plug or patch is not required.

The walls of the first and second luminal structures may collapse as thecollapsing sleeve 4120 is withdrawn to occlude the opening created bythe central member. However in another embodiment, a plug 4124 may bedeposited in any remaining opening to artificially occlude the opening.This may be important to limit the amount of fluids that escape out ofthe luminal structures. This plug 4124 may also be a patch or a stopper.Alternatively the opening may also be closed through the use of otherwell known closure devices such as staples, sutures, or adhesives.

As shown in FIG. 29, the device may have a valve member 4116 that isattached to the proximal end of the central member 4108. The valve is asock like member that is designed to restrict fluid flow to onedirection. Preferably the valve member 4116 prevents fluid flow from thefirst luminal structure A to the second luminal structure B. The valvemember may act similarly to a wind sock or a one way flap valve in thatthe valve functions because the diameter of the proximal end of thevalve, the neck 4114, is collapsed as compared to the diameter where thevalve attaches to the central member to a small closed neck. Theproximal tip 4118 has an opening so that instruments can be passedthrough the valve 4116 and into the second luminal structure B. Thevalve is capable of opening to accommodate passing instruments throughit but quickly closes once these instruments are removed to restrictfluid flow to a single direction. The preferred direction of fluid flowis from the second to the first luminal structure although this could bereversed if necessary without affecting the function of the device.

This invention has been described and specific examples of the inventionhave been portrayed. The use of those specifics is not intended to limitthe invention in anyway. Additionally, to the extent that there arevariations of the invention, which are within the spirit of thedisclosure or equivalent to the inventions found in the claims, it is myintent that this patent will cover those variations as well.

What is claimed is:
 1. A system to form a fluid pathway between adjacenttissue layers of a first luminal body and a second body comprising: apenetrating member; a central member forming a lumen and having a middleportion, distal and proximal end portions, and a lumen diameter; and themiddle portion, the distal end portion and the proximal end portionconfigured to move from a first configuration to a second configuration,whereby, in the second configuration, a length of the middle portionbetween the distal and proximal end portions decreases and the lumendiameter of the central member along the middle portion increases andrespective non-overlapping distal and proximal retention membersseparated by a distance along the middle portion are formed, the distaland proximal retention members comprising bent portions forming curvesto present an atraumatic interface to appose the adjacent tissue layersof the first luminal body and second body, and terminal ends of the bentportions extend away from the adjacent tissue layers and are free ofcontact with the adjacent tissue layers.
 2. The system of claim 1,wherein the first luminal body and second body are selected from thegroup consisting of the: esophagus, stomach, small intestine, colon,bladder, gallbladder, uterus, or bronchotracheal tree.
 3. The system ofclaim 1, further comprising: a sheath configured to provide a radialrestraint on the central member in the first configuration.
 4. Thesystem of claim 1, wherein the central member is configured to beremoved after formation of an anastomosis between the first luminal bodyand second body.
 5. The system of claim 1, wherein the penetratingmember comprises a needle.
 6. The system of claim 1, wherein at least aportion of the central member includes a covering or membrane.
 7. Thesystem of claim 1, wherein the central member includes a self-expandingmesh.
 8. The system of claim 1, wherein the central member, includingthe middle portion, distal retention member and proximal retentionmember, in the second configuration, are a stent.
 9. The system of claim1, wherein the first luminal body and second body are segments of thebowel.
 10. The system of claim 1, wherein the second body is a ductalstructure.
 11. The system of claim 1, wherein the first luminal body isthe stomach and the second body is the bowel.
 12. The system of claim 1,wherein the first luminal body is the stomach and the second body is thegallbladder.
 13. The system of claim 1, wherein the distal and proximalretention members form radially expanded flanges when in the secondconfiguration.
 14. The system of claim 13, wherein the first luminalbody is a stomach.
 15. The system of claim 14, wherein the second bodyis a neighboring tissue structure to the stomach.
 16. The system ofclaim 1, whereby, in the second configuration, at least a portion of thedistal retention member bends back over the middle portion, and at leasta portion of the proximal retention member bends back over the middleportion.
 17. A medical device to form a fluid pathway between adjacenttissue layers of a first luminal body and a second body, comprising: acentral member defining a lumen for the fluid pathway, the centralmember having a middle portion, a lumen diameter, a distal end portionand a proximal end portion; and the distal end portion including adistal retention member and the proximal end portion including aproximal retention member, in an expanded configuration, whereby, in theexpanded configuration, the distal retention member and the proximalretention member are separated and non-overlapping along the middleportion, a length of the middle portion is decreased and the lumendiameter of the central member along the middle portion is increased,the distal and proximal retention members comprising bent portionsforming curves to present an atraumatic interface to appose the adjacenttissue layers of the first luminal body and second body, and terminalends of the bent portions extend away from the adjacent tissue layersand are free of contact with the adjacent tissue layers.
 18. The deviceof claim 17, whereby, in the expanded configuration, at least a portionof the distal retention member bends back over the middle portion, andat least a portion of the proximal retention member bends back over themiddle portion.
 19. A drainage device to form a fluid pathway betweenadjacent tissue layers of a first luminal body and a second body,comprising: a central member forming a lumen for the fluid pathway andhaving a middle portion, a lumen diameter, a distal end portion and aproximal end portion; the distal end portion configured to move from afirst configuration to a second configuration to form a distal retentionmember; and the proximal end portion configured to move from a firstconfiguration to a second configuration to form a proximal retentionmember, whereby, in the second configuration of the distal retentionmember and the proximal retention member, the distal and proximalretention members are non-overlapping and separated by a distance alongthe middle portion, a length of the middle portion is decreased and thelumen diameter of the central member along the middle portion isincreased, the distal and proximal retention members comprising bentportions forming curves to present an atraumatic interface to appose theadjacent tissue layers of the first luminal body and second body, andterminal ends of the bent portions extend away from the adjacent tissuelayers and are free of contact with the adjacent tissue layers.
 20. Thedevice of claim 19, whereby, in the second configuration of the distalretention member and the proximal retention member, at least a portionof the distal retention member bends back over the middle portion, andat least a portion of the proximal retention member bends back over themiddle portion.